- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $107.15 / $107.15
| Facility | | $104.71 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $107.15 / $173.78
| Professional | | $89.13 | $107.15 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $218.78
| Facility | | $204.17 | $204.17 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $257.04
| Professional | | $123.03 | $123.03 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $141.25
| Professional | | $107.15 | $107.15 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $173.78 / $173.78
| Facility | | $112.20 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $134.90
| Professional | | $125.89 | $125.89 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $204.17 / $288.40
| Professional | | $151.36 | $204.17 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $134.90 / $199.53
| Professional | | $123.03 | $134.90 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $147.91 / $257.04
| Facility | | $87.10 | $147.91 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $120.23 / $131.83
| Professional | | $109.65 | $120.23 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $165.96 / $588.84
| Facility | | $114.82 | $165.96 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $165.96 / $588.84
| Professional | | $114.82 | $165.96 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $147.91 / $204.17
| Facility | | $75.86 | $147.91 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $100.00 / $158.49
| Professional | | $95.50 | $100.00 | $158.49 |